Case Worksheet for Learners

Case Worksheet for Learners Case Goal Children with autism spectrum disorder (ASD) present with similar development issues and challenges to typically developing children, but special consideration may be needed when evaluating these issues and providing anticipatory guidance to families. Key Learning Points of This Case 1. Recognize some of the common developmental issues that present in children with ASD and how to evaluate them. a. Describe the different types of sleep problems seen in children with ASD. b. Provide a differential diagnosis for feeding problems in children with ASD c. Describe the common challenges to toilet training in children with ASD 2. Identify management approaches and strategies for the common developmental issues seen in children with ASD a. Describe behavioral strategies that may promote improved sleep in children with ASD b. Identify the indications for using medications in the treatment of sleep difficulties. c. Recognize strategies to improve eating habits in children with ASD d. Become familiar with techniques for toilet training children with ASD Post Learning Exercise Read the article: Kodak T, Piazza C. Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders; Child Adolesc Psyciatr Clin N Am. 2008;17(4):887-905 19

Case Study Part I Jack is a 3 ½-year-old boy recently diagnosed with an ASD. His mother brings him to your office today for his wellchild visit. You begin by asking if she has any concerns and she reports Jack has been having difficulty falling asleep. Before going to bed, he has an elaborate ritual. He refuses to sleep by himself and will only sleep with an empty soda bottle. She has to lie beside him until he falls asleep, which takes anywhere from 30 minutes to an hour. He wakes up three to four times in the middle of the night looking for her. He refuses to go back to bed unless she lies back down with him. His bedtime is at 7 p.m. and, although she wishes he would sleep longer, he wakes up like clockwork at 5 a.m. His mother notices he gets cranky in the afternoon, so she tries to enforce an afternoon nap. Some days he takes a nap easily; other days he fusses. When you ask if he snores, she chuckles and mentions that for a little person, he snores like a truck. His mother states that she feels exhausted all the time, and she has a short fuse. Case Authors Shanna Kralovic, DO, Rainbow Babies and Children s Hospital. University Hospitals Case Medical Center Anna Maria S. Ocampo, MD, Children s Hospital Boston, Harvard Medical School 20

Case Study Part II Realizing that you must move on with the visit, you ask about Jack s eating habits. Jack s mother describes him as a picky eater who refuses to drink milk. He prefers to eat chicken nuggets, crackers, toast, cheese, and grapes, and he drinks mostly juice. With such a limited diet, you ask whether he has problems with constipation or diarrhea. In fact, he is only stooling every few days, and his stools are very hard. Jack s mother has been trying to toilet train him for the past six months without success. He has never had a bowel movement on the toilet. Recently, she started having him sit on the toilet once a day after dinner, right before his bedtime routine. Jack will urinate in the toilet when asked to do so, but does not go to the bathroom on his own to urinate. Case Authors Shanna Kralovic, DO, Rainbow Babies and Children s Hospital. University Hospitals Case Medical Center Anna Maria S. Ocampo, MD, Children s Hospital Boston, Harvard Medical School 21

Case Study Handout Part III Epilogue You are concerned about the history of constipation and ask Jack s mother a few more questions while you perform the physical exam. Has he had any diarrhea (i.e., overflow leakage of stool associated with constipation)? Is there blood with the stools? Can she tell or can Jack communicate whether he experiences pain with the bowel movements? What has she tried to help the constipation? He has not had any recent diarrhea or blood with his stools. She is unsure whether he is having pain with bowel movements because he goes in his diapers. She thought the fruit juice would help, so she lets him have it whenever he asks. Your abdominal physical exam is normal, although Jack was slightly uncooperative. You decide to defer the rectal exam. You give Jack a stool softener and ask his mother stop toilet training at this time. You schedule a follow-up appointment so you can devote more time to discussing Jack s diet, toileting issues, and sleep. You also refer him to an otolaryngologist for evaluation of possible sleep apnea. Case Authors Shanna Kralovic, DO, Rainbow Babies and Children s Hospital. University Hospitals Case Medical Center Anna Maria S. Ocampo, MD, Children s Hospital Boston, Harvard Medical School 22

Handout I: Causes of Insomnia in Children with ASD Neurobiological (e.g., synaptic transmission deficiency, metabolism) GABA Melatonin Behavioral Inadequate sleep hygiene Inappropriate sleep-onset association Improper limit-setting Coexisting neurologic disorders (e.g., epilepsy) Coexisting medical disorders (e.g., gastrointestinal, gastroesophageal reflux disease) Coexisting psychiatric disorder (e.g., anxiety) Food and medications (e.g., caffeine, corticosteroids, bronchodilators) Other sleep disorders Obstructive sleep apnea Restless leg syndrome Periodic limb movements of sleep Delayed sleep-phase disorder Irregular sleep-wake rhythm Johnson KP, Malow BA. Assessment and Pharmacologic Treatment of Sleep Disturbance in Autism. Child and Adolescent Psychiatric Clinics of North America; Vol 17;2008;pp. 773-785. 23

Handout II: Clinical Properties of Selected Medications Used for Pediatric Insomnia Drug Alpha-2 agonist Clonidine Antihistamines Diphenhydramine Bronpheniramine Chlorpheniramine Hydroxyzine Atypical antidepressants Trazodone Benzodiazepine receptor agonists Benzodiazepine Clonazepam Flurazepam Quazepam Temazepam Estazolan Triazolam Benzodiazepine receptor agonists Non-benzodiazepine Zolpidem Zaleplon Eszopiclone Melatonin Synthetic melatonin receptor agonist Ramelteon Side Effect Dry mouth, dizziness, drowsiness, headache, sedation, fatigue, weakness, constipation Daytime drowsiness, GI problems (appetite loss, nausea/vomiting), constipation, dry mouth), paradoxical excitation Dizziness, CNS overstimulation, cardiac arrhythmias, hypotension, priapism Residual daytime sedation, rebound insomnia on discontinuation, psychomotor/ cognitive impairment, anterograde amnesia (dose dependent), impairment of respiratory function Headache, retrograde amnesia, few residual next-day effects Drowsiness and headaches No significant side effects Suggested Citation: Kralovic, S., Ocampo, A.M.S. Clinical Properties of Selected Medications Used for Pediatric Insomnia. Developed for the A Developmental-Behavioral Pediatrics Curriculum. 2011. 24

Handout III: TEACCH Toileting Chart with Picture Icons Pull down pants Pull down underwear Sit on toilet Use toilet paper Pull up underwear Pull up pants Flush toilet Go play Boswell S, Gray D. Applying Structured Teaching Principles to Toilet Training. TEACCH Autism Program website. 2006. http://teacch.com/educational-approaches/applying-structured-teaching -principles-to-toilet-training-susan-boswell-and-debbie-gray. Accessed January 21, 2013. 25

Autism Spectrum Disorder-Specific Anticipatory Guidance Handout IV: Algorithm for Treatment of Constipation in Children 26

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